Kathleen Kozak – Honolulu Civil Beathttps://www.civilbeat.org
Honolulu Civil Beat - Investigative ReportingWed, 19 Dec 2018 07:05:31 +0000en-UShourly1https://wordpress.org/?v=4.9.9Health Beat: When Your Boss Gets To Decide Where You’ll Have Surgeryhttps://www.civilbeat.org/2018/12/health-beat-when-your-boss-gets-to-decide-where-youll-have-surgery/
Mon, 17 Dec 2018 10:01:01 +0000https://www.civilbeat.org/?p=1312790Many large employers are self-insured for their health care costs. That means the premium dollars that are paid, either by the worker or the company, are used for direct medical costs, often through an intermediary health insurance plan. If workers are healthy, medical costs are low. If workers are sick, the company pays more. Statistics […]

]]>Many large employers are self-insured for their health care costs. That means the premium dollars that are paid, either by the worker or the company, are used for direct medical costs, often through an intermediary health insurance plan.

If workers are healthy, medical costs are low. If workers are sick, the company pays more.

Statistics show that 80 percent of companies with 1,000 or more employees are self-insured.

The advantages include the ability to pay only for the services that employees use, and keep any extra money in reserves. This also allows for customization of the plan, adding features specific to workplace needs, which may not be readily available with standard commercial insurance plans. There are also possible tax advantages with these self-funded plans.

But there are potential disadvantages as well. The control that can be exerted harkens back to an earlier time before insurance even existed.

Can the boss dictate where workers go to get their medical care?

Walmart, which employs more than a million people, thinks so.

As big companies try to control costs, they’re also reducing the medical care choices for their employees.

Flickr.com/libertygrace0

Starting in January 2019, Walmart will require its employees to use certain hospitals for costly spine surgeries, hoping to save money by using physicians who might be more conveniently located.

The program started in 2013 on a voluntary basis. Workers were enticed by the company paying travel costs and by significantly reduced or eliminated copays.

In a recent analysis, Walmart noted that half of the workers who had volunteered to travel for their care were able to avoid surgery entirely. Major spine centers were less aggressive about recommending surgery, opting for a more conservative approach to spinal care. This reduces the risk for surgical infections and complications, and completely avoids surgical recovery time.

The entire insurance industry actually arose from the desire of workers to have more freedom to choose providers while still having their health care subsidized by employers.

Hospital systems such as the Mayo Clinic, Geisinger Medical Center in Pennsylvania, and Memorial Hermann Health Systems in Texas are all participating in the program in partnership with Walmart.

Other major employers have also partnered with designated health care centers. Lowe’s employees have the option to travel to major centers for certain heart, orthopedic and spine procedures.

The role of the employer to determine the location of medical care is not a new phenomenon. Here in Hawaii, the earliest health care systems were based on the plantation doctor model, where the companies would pay a doctor to exclusively take care of their workers for a set fee.

The entire insurance industry actually arose from the desire of workers to have more freedom to choose providers while still having their health care subsidized by employers.

Nevertheless, Apple has created a health campus in Santa Clara, a few miles north of its headquarters in Cupertino. The plan is to provide company-employed primary care doctors, exercise coaches, and health care navigators.

Amazon, JPMorgan Chase and Berkshire Hathaway have all aligned to focus on changing health insurance for their employees. The companies are self-funding the insurance costs for 1.2 million people.

The goal is to provide a more efficient model of care, but the practicalities have yet to be worked out. And the changes potentially prioritize cost considerations over other less measurable factors, like family support and recovering at home.

As the efforts to contain costs in medicine continue, there needs to be a shift in the plan for saving money to a plan for increased overall quality of care. Rather than requiring patients to travel to major centers for routine procedures, a greater effort should be made to support the quality of care from the local hospitals as well.

Diverting resources to other major medical centers sounds like a good way to reduce overall costs for the employer, but if local hospitals close due to the lack of revenue from their daily operations, then employees may lose in the long run. Emergency rooms may not be available, and routine care for conditions like pneumonia would require lengthy travel to the few hospitals that survive the downturn.

If the boss can demand that medical care has to be provided in at a specific location, this could also stretch the major medical centers to compete with each other on cost, leading to a bidding war for the cheapest price for a hip replacement.

Should medical care be chosen based on the potential profits for a company, or on the most appropriate care for the patient? Will innovation in future hip replacements be stifled because the only covered services are those that cost the least?

Self-funded medical insurance is not a new concept, but the potential implications of offering surgery in a limited number of medical centers do not propel the medical industry forward with improved quality of care.

When the boss who pays the bills can dictate who gives the care and where, how much different is that than the old plantation days?

]]>Health Beat: ERs And Urgent Care Clinics Should Be Side By Sidehttps://www.civilbeat.org/2018/12/health-beat-ers-and-urgent-care-clinics-should-be-side-by-side/
Thu, 06 Dec 2018 10:01:24 +0000https://www.civilbeat.org/?p=1310311It’s Friday night, and you have felt sick all day. All week you have kept it together to go to work, not wanting to miss a day during the holiday season. You don’t have a fever, but you wonder what’s going on, and want to see your doctor for advice. That’s not possible at this […]

All week you have kept it together to go to work, not wanting to miss a day during the holiday season. You don’t have a fever, but you wonder what’s going on, and want to see your doctor for advice. That’s not possible at this late hour, the office is closed until Monday.

You might consider going to an emergency room. After a couple of lab tests, some intravenous fluids, and a prescription for antibiotics, you’d be good to go.

But the cost of the ER visit could end up being upwards of $2,000 — more if additional testing is done like a CT scan or x-ray.

If you had seen your doctor in the office when the illness started — or went to an urgent care center Friday night — the bill might be less than 10 percent of the ER charge.

The Queen’s Medical Center emergency room parking lot. If hospitals had their own urgent care clinics, they could take some of the load off the ERs.

Cory Lum/Civil Beat

ER visits are expensive, and many are unnecessary because they’re for routine conditions like minor bladder infections, colds and coughs, prescription refills, low back pain, twisted ankles, etc.

But often the reason someone goes to the ER is because they feel it could be an emergency, and don’t have the medical training to know otherwise. It might be the only place available after hours, or their symptoms might have gotten worse and they are worried about getting pneumonia, or having a fracture.

There are certainly legitimate reasons to go to the ER, such as people who are seriously injured or fear they are having strokes or heart attacks. It’s these folks who need emergency care, possibly urgent surgery or life-saving medications. However, serving patients who could be somewhere else can tie up ER doctors and make those with real emergencies wait.

There is an alternative for nonemergency visits. Urgent care centers are a great place to get care for many of these conditions. But once someone decides to head to the ER, they have used their best judgment and are on their way.

What if hospitals provided both ERs and urgent care clinics in the same general location.

Simple things could be taken care of at the urgent care area. This would shorten the waiting time for true emergencies.

Patients who show up at the ER could be triaged by highly trained nurses to go to the actual emergency room or to the on-site urgent care section. Everyone would be seen, but the venue would be decided by medical personnel.

Simple things could be taken care of at the urgent care area. This would shorten the waiting time for true emergencies and also allow for an easy transfer to the ER if the person who was seen in the urgent care area needed more help than was anticipated.

Ancillary testing could be provided, with no extra cost to the facility since the services are already available for the ER. This could include x-rays and lab testing — services that are often not immediately available in a separately located urgent care.

This co-location could also be staffed by nurse practitioners and physician assistants that would have direct access to physicians rather than the way some of the current clinics are staffed, which requires transfers via ambulance to the ER for anything that is too complex for the provider to handle alone.

Hospitals would benefit by having another option for care for patients, which would lessen the amount of money they currently spend on highly trained emergency personnel who wind up taking care of low acuity patients.

Uninsured patients would benefit because they would not have to pay for the high cost of emergency care if they only needed something that an urgent care-like visit could handle. Medical bankruptcies from high ER charges might even be reduced.

Insured patients would also benefit because the overall cost of care for all members has the potential to go down, thus lowering premiums for coverage. Given the fact that many visits to ERs are considered unnecessary, there are potentially millions of dollars that can be saved in payments to lesser acuity areas.

Hospitals will not be paid separately for each ER visit in the near future, instead receiving a set amount to care for all of their patients, regardless of which part of the hospital they’re in. Creating a mechanism to identify the correct location is key to the success of these accountable care organizations.

Finding more cost-effective alternatives that will provide comprehensive care options for patients is a must. Co-locating an urgent care next to an ER will put the responsibility on highly trained medical staff to appropriately identify which patients have a true emergency, while alleviating the patients from having to make the choice themselves.

]]>Health Beat: The Cost Of Curing Cancer May Become Unaffordablehttps://www.civilbeat.org/2018/11/health-beat-the-cost-of-curing-cancer-may-become-unaffordable/
Tue, 20 Nov 2018 10:01:03 +0000https://www.civilbeat.org/?p=1308582The cure for cancer has remained an elusive Holy Grail in medicine, with billions of dollars being spent on research hoping to find a way to prevent or treat this often fatal disease. With the National Cancer Institute combining forces with former Vice President Joe Biden’s Cancer Moonshot program, efforts have been made to coordinate […]

]]>The cure for cancer has remained an elusive Holy Grail in medicine, with billions of dollars being spent on research hoping to find a way to prevent or treat this often fatal disease.

With the National Cancer Institute combining forces with former Vice President Joe Biden’s Cancer Moonshot program, efforts have been made to coordinate resources across the federal government to speed progress in cancer research in the areas of prevention, detection, and hopefully a cure.

As a result of this intense focus on curing cancer, advances have been made in the field of cancer genomics — researching the specific genetic abnormalities that cause a mutation in the genetic code, and result in cancer cells in the human body.

The results have been surprising. Cancers in areas thought to be completely unrelated to one another have been found to have the same genetic mutation, and thus can be treated with the same type of medication. Melanoma, lung and colorectal cancer, for instance, are both found to be associated with the B-RAF mutation, now a target for treatment with Zelboraf, the brand name for Vemurafenib.

Drug companies are controlling both cancer diagnostic testing and treatment, which is driving costs up.

Cory Lum/Civil Beat

However, the problem arises with the cost of these treatments. Zelboraf costs $13,000 a month with the total cost for a full course of treatment estimated at over $200,000. Although the federal government is involved in the funding of many of the initial discoveries leading to precision medicine’s advances, once the technology is sold to private companies, the costs can go up exponentially, even with competition in the market from other medications.

Could curing cancer become so expensive, we can’t afford it?

The pharmaceutical industry has quietly begun to monopolize the process of cancer detection, genetic analysis and treatment with no control on the prices they charge for their proprietary services. Roche pharmaceuticals has purchased Foundation Medicine, a company that does the analysis of biopsy specimens to determine the genetic analysis to see if there are “targetable mutations” for treatment — genetic abnormalities for which new forms of immunotherapy can be considered.

Who makes the immunotherapy? Well, Roche of course.

Roche also purchased Flatiron Health, the company known for doing real-world studies, now recommended by the Food and Drug Administration, especially for drugs which are fast tracked to market.

With the clear financial incentives to find mutations that their products can treat, who can put a ceiling on the cost to diagnose and treat cancer?

At the moment, there is no overarching organization that controls the cost of care for cancer patients. Average cost for genetic analysis on a biopsy specimen can run into the thousands of dollars. Average cost for the treatment: up to several hundred thousand dollars.

No one wants to see the research into the cure for cancer be stopped before it’s found. But as further advances lead to advanced genomic testing and other treatment options, the commercialization of the diagnosis and treatment have led to such high costs that the system may not be sustainable much longer.

Presently, if a patient is diagnosed with cancer, and they have medical insurance, the cost of much of their care is covered. However, as more and more treatments are developed, and the monopoly of the diagnostic and therapeutic testing is owned by just a few of the major pharmaceutical companies, the cost of care is going to be greater than even any insurance company can bear. Premiums will rise, and fewer people will be able to afford insurance at all.

What happens next is unknown. In the Medicare system, the taxpayers would have to pay for the cost of care. Same in the Medicaid system, where the joint funding from the federal government and each state would have to be great enough to cover the costs. The amount of money that is spent on health care in the United States is already almost 18 percent of the GDP. Many states can’t afford a huge increase in the cost of Medicaid spending.

Anyone without insurance who doesn’t qualify for government programs is at the mercy of their own finances, or perhaps gofundme campaigns to pay for their care. Some people may not even pursue treatment due to cost.

But given the fact that much of the research is being done with federal funding, shouldn’t there be some limitation on the cost of the testing and treatment, even if the discoveries are sold to private industry? Taxpayers are funding the research, why are they being double-charged through their payment for Medicare, Medicaid, and their own private insurance to pay for the same discoveries that they helped fund?

Something has to limit the extent to which the pharmaceutical industry sets the cost for both the testing and treatment of cancer.

Ignoring this lack of cost control will make the treatment of cancer unaffordable, and the overall cost of care unsustainable. People with cancer should not have to go broke to survive, or die because they can’t pay for the very treatments their tax dollars helped fund.

]]>Health Beat: This Simple Rule Change Could Lower Medicare Costshttps://www.civilbeat.org/2018/11/health-beat-this-simple-rule-change-could-lower-medicare-costs/
Fri, 02 Nov 2018 10:01:40 +0000https://www.civilbeat.org/?p=1307075Medicare is the predominant insurance for anyone 65 or older, and almost all hospitals and most physicians participate in the program. But the cost of health care has increased to almost 18 percent of the gross domestic product, and there are efforts afoot to lower the overall cost of care for everyone. A large chunk […]

]]>Medicare is the predominant insurance for anyone 65 or older, and almost all hospitals and most physicians participate in the program. But the cost of health care has increased to almost 18 percent of the gross domestic product, and there are efforts afoot to lower the overall cost of care for everyone.

A large chunk of the costs are incurred in the last few years of life, so care for older patients is a big focus of the efforts.

One part of the solution involves skilled nursing facilities, which provide services like physical therapy, medication management, complicated wound care, use of feeding tubes and management of any type of breathing assistance with a machine.

These services are cheaper than regular hospital care, but there’s a catch known as the three-day rule.

Medicare’s three-day rule can keep patients in the hospital longer than they need to be.

Flickr.com

Medicare will only pay for skilled nursing care if a patient has already been in the hospital for three days. This results in either patients being denied coverage and being sent home instead, or more likely being kept in the hospital longer just to meet the three-day requirement, and thus incurring more costs for those extra days while occupying a bed that could be used for someone else.

In an experiment, some health systems have been exempted from the three-day rule, and they’re reportedly saving millions of dollars as a result.

Which raises the question: Why hasn’t the three-day rule been completely eliminated?

Hospitals across the nation are facing cuts as reimbursements fail to keep up with the overall cost of care. Many smaller ones are closing.

Hawaii hospitals would benefit from elimination of the rule. Currently the three-day requirement keeps patients in the hospital, and delays in transfers lead to higher costs for the hospitals without reimbursement to match. Also, even one day could change the availability of a bed at a skilled nursing facility, and lead to further costly hospital days until another one is open.

The rule change would also benefit patients who have same-day surgery and then need a skilled nursing facility.

Cory Lum/Civil Beat

Patients who have same-day surgery and need a few days in a skilled nursing facility would be eligible for admission right after their hospital procedure. Patients who are admitted with pneumonia, cellulitis or other conditions that could be started on a treatment protocol in one to two days could be sent to such a care facility, with an extra day or two in the hospital avoided.

The bottom line of the hospitals would improve, as other patients could be admitted, and skilled nursing facilities might see a higher rate of admissions to boost their bottom lines as well.

Patients would not be kept in the hospital longer than they need to be, or discharged home because Medicare would not cover their skilled nursing facility care.

For hospitals that have extra beds available, opening up a wing to provide skilled nursing care would also lower costs as the staffing needs and overall charges are lower than a standard hospital floor. This keeps the flexibility of having the location be changed to a regular hospital floor if demand increases, but also would help to streamline the discharge process if patients are transferred to another floor, and not to another location.

Some health systems have been exempted from the three-day rule, and they’re reportedly saving millions of dollars as a result.

The biggest boost would be for those hospital systems that already have a skilled nursing facility, or a close partnership with one, so that the transfer process is seamless.

The advantages of eliminating this rule could be even greater over time.

The initial report from the 2016 cohort of health systems was just released, and each of those centers may see further improvements in the years to come. As more and more patients are being treated in hospitals and sent home with care plans in place, the need for interim facilities is only going to increase.

Eliminating the three-day rule won’t fix all of the problems associated with health care costs, but it is a proven approach that all heath care providers deserve to benefit from.

]]>Health Beat: Mergers May Give Medical Industry A Shot In The Armhttps://www.civilbeat.org/2018/10/health-beat-mergers-may-give-medical-industry-a-shot-in-the-arm/
Thu, 25 Oct 2018 10:01:53 +0000https://www.civilbeat.org/?p=1305633There have been a lot of recent mergers within the health care industry – insurance companies and pharmacy benefit managers, such as Cigna and Express Scripts, CVS and Aetna. Walmart has hinted at a merger with Humana. Amazon has committed to creating their its own health care plan to disrupt the industry. Apple has posted […]

]]>There have been a lot of recent mergers within the health care industry – insurance companies and pharmacy benefit managers, such as Cigna and Express Scripts, CVS and Aetna.

Walmart has hinted at a merger with Humana. Amazon has committed to creating their its own health care plan to disrupt the industry. Apple has posted jobs for physicians to work at its campus in Palo Alto, California.

What’s next?

Will merger mania just make health care more complicated? Or might it be the antidote for an industry that has been moving at a glacial pace to change course and lower the rampant inflation in health care costs?

Amazon headquarters Seattle. The company has committed to creating its own health care plan

simone.brunozzi/Flickr.com

Right now, the way things work in most systems is a bit fragmented. People pay premiums to their health insurance company to cover the administrative costs of running the company in addition to the cost of care for the subscribers.

These costs of care are spread out over all hospitals, each with their own cost structure, overhead and administration. There are also charges associated with diagnostic testing, radiological imaging, and all manners of care that are provided, in surgical centers and private offices.

Hospitals want to stay in business, so the cost of care for the uninsured is spread out over all those who do have insurance to cover the losses. Many of the uninsured just can’t afford the premiums for coverage anymore, and with the loss of the mandate, no longer have to carry insurance for their care.

Pharmaceutical costs are also skyrocketing, and most insurers partner with a pharmacy benefit manager to handle the medication portion of the health insurance plan. That results in additional overhead to help pay for the administrative costs of the manager, in addition to the cost of medication that is prescribed for the members. Last year, Express Scripts made over $4.5 billion dollars in business activities.

Making changes to this system requires a multi-company commitment to lowering overhead and administrative costs and combining with others to do the same.

But as with most endeavors, it’s very difficult to get everyone on the same page at the same time.

What could consolidation do to help?

First, it might lower the overhead costs for each separate entity. Money can be saved on the administrative time that it takes to have an insurance company work with different pharmacies by having a benefits manager handle all medication claims. Savings should be funneled into lowering the cost of insurance, especially if we keep the requirement that insurance companies spend 85 percent or more of their collected premiums on health care services.

The merger of CVS and Aetna might provide additional opportunities for care to be delivered in a wider variety of locations, like urgent care offices or minute clinics that offer expanded hours for the working population or those who need help after-hours. Emergency care could be provided at a lower-cost location. The savings are direct to the insurance company, but should translate into lower costs for individual insurance plans. That means lower premiums, in an ideal world.

Medical supplies and equipment represent another area of opportunity. Amazon has an internet-based shipping network that reaches worldwide. The market is wide open to provide telemedicine services to remote locations and medication shipping to any address in the U.S. within a few days, if not the same day. The bulk savings alone would be an advantage that is unmatched, except perhaps by another giant, like Walmart.

Over 10 years ago, Walmart slashed the price of some generic drugs to $4 and began to dominate the pharmacy business by lowering the cost of medications almost overnight. Since then, it has opened 19 health clinics, in addition to offering vision centers and screening events in their stores. Its employee base of 2.2 million workers provides a great incentive to lower the overall cost of care, as it is a self-insured employer bearing all of the health care costs for their workers directly.

Its possible partnership with Humana could result in offering its own brand of health care. Many older Walmart shoppers are no doubt looking for cheaper alternatives to the standard costs of care in the marketplace. Many of the stores are in rural locations with doctor shortages.

Major employers already are partnering with medical centers of excellence like the Cleveland Clinic and Mayo Health Systems in an effort to eliminate the middle man of the health insurer, and provide care directly at a pre-set costs. By establishing direct contracts with these major powerhouse medical centers, the employers who pay for the cost of health care for their workers are now improving their own bottom line, potentially offering greater salaries to their employees and increasing the profits for investors.

The potential disruptions of all this to the health care industry are endless. But the old way of doing business is going to be gone soon, and those who are creating the integrated health care delivery system of the future will need to take a fresh approach to providing care in new ways, new locations, and under one virtual roof.

Thoughts on this or any other story? Write a Letter to the Editor. Send to news@civilbeat.org and put Letter in the subject line. 200 words max. You need to use your name and city and include a contact phone for verification purposes.

You can also comment directly on this story by scrolling down a little further. Comments are subject to approval and we may not publish every one.

]]>Health Beat: A Simple Way The US Could Save A Bundle On Medical Costshttps://www.civilbeat.org/2018/09/health-beat-a-simple-way-the-us-could-save-a-bundle-on-medical-costs/
Wed, 19 Sep 2018 10:01:13 +0000https://www.civilbeat.org/?p=1300318The United States currently spends over 17 percent of the its Gross Domestic Product on health care, more than $3 trillion annually, or more than $10,300 per person. Despite this large investment, patients are no healthier here than in many developed nations who all receive care at a lower overall cost. The reasons for this are […]

But the thing that could immediately lower costs has eluded everyone so far: mandatory sharing of all electronic records into a centralized database with full access for clinicians and patients.

In a recent survey of clinicians, up to one-third of care was found to be unnecessary. This includes testing that is not known to improve health, or defensive ordering of diagnostics to avoid malpractice, but also duplication of testing already done elsewhere.

Medication errors abound, worsened by not having a cohesive database of which pills patients formerly took and what they’re taking now.

And management of many conditions is entirely different if there are previous tests available to review, particularly with X-rays and CT scans. Lab testing that has recently been completed by other providers is frequently duplicated since access to outside testing is limited.

Testing is expensive. Millions of laboratory tests are done each year. I see duplicated labs that are unnecessary several times a week because patients see doctors or other providers that are not part of the electronic medical record that I use.

Patients have access to their test results, but not many bring in a printout of their last five years of results, and if they can find the numbers, it may not include all of the tests. Although efforts are made to get outside records, these are faxed to medical offices, and not in a searchable format so that all former blood counts, for example, could be reviewed to see if there was a change.

A universal lab portal would eliminate the need to have paper faxes traveling between medical record departments and doctor’s offices. Trends in testing for cholesterol, sugar, liver numbers — all of this should be easily accessible with a few clicks of a mouse.

With the average blood panel costing several hundreds of dollars, this adds up.

Currently, if a patient goes to a local pharmacy for one prescription from me, and a mainland pharmacy for their prescription from another doctor using a different electronic medical record, I don’t see it in their records when they come in for a visit.

Periodically I get notified by insurance companies about the potential adverse reaction to certain medication combinations. I may have only prescribed one of the offending pills, and often when I look in my record, there isn’t a notation made of the other medication being taken regularly.

The Hawaii Prescription Drug Monitoring Program is a statewide database designed to list all opioid medications that patients are taking, and as of July 1, every prescriber has to check this system before giving an opioid prescription to their patient. If the system can be set up for opioids, it can be set up for all medications. The technology is already available.

There should also be a statewide database for X-rays, CT scans and MRIs. Often, there are subtle findings on scans that might have been there before but are potentially troublesome when there is no comparison from prior films. Knowing the progression might eliminate the need for invasive follow-up testing like lung or liver biopsies.

Frequent scans also expose patients to excess radiation, which over time may be harmful.

I see duplicated labs that are unnecessary several times a week.

A centralized medical record system could avoid that.

Each proprietary system would remain, but it should download into a larger database that can systematically list what testing was done elsewhere. Artificial intelligence could be put to use organizing tests such as scans, X-rays and EKGs into a convenient, comprehensive, searchable database.

After all the years of paper charts, almost 90 percent of doctors are using some type of electronic medical record. Coordination of these systems could provide an almost universal medical record for the entire United States.

Our nation needs an overhaul of the way health care is provided and paid for. Creating a national medical record system may be the first step.

Thoughts on this or any other story? Write a Letter to the Editor. Send to news@civilbeat.org and put Letter in the subject line. 200 words max. You need to use your name and city and include a contact phone for verification purposes.

And you comment directly on this story by scrolling down a little further. We are enabling comments on some stories in the spirit of having a robust community conversation.

]]>Health Beat: Watch Out, This Medicare Scam Begins With A Phone Callhttps://www.civilbeat.org/2018/09/health-beat-watch-out-this-medicare-scam-begins-with-a-phone-call/
Tue, 04 Sep 2018 10:01:49 +0000https://www.civilbeat.org/?p=1297320Watch your back! And in particular, companies looking to profit off your backaches. Recently I received a fax from a company with the motto, “nothing to lose but the pain.” On the front was a picture of Joe Namath, a former pro football quarterback who is all-too-familiar with pain. The fax said a patient of […]

]]>Watch your back! And in particular, companies looking to profit off your backaches.

Recently I received a fax from a company with the motto, “nothing to lose but the pain.” On the front was a picture of Joe Namath, a former pro football quarterback who is all-too-familiar with pain.

The fax said a patient of mine had contacted the company and was requesting “an insurance approved product in order to reduce pain and/or assist with their medical condition.”

All it required was my signature. The next page was a pre-filled prescription, and the requested medical equipment of a back brace, shoulder brace and knee brace.

Doctors can be taken in by scams that make it easy to sign off on medical equipment their patients don’t really need.

Ale Proimos/Flickr.com

It seemed odd, since this patient has a history of arthritis, but no pain, and generally gets along fairly well. She has refused pain medication or any surgery for her condition.

But these things come across my desk every once in awhile. Diabetic shoe requests for a patient who doesn’t have diabetes but was watching a commercial about qualifying for free shoes late at night. Scooters for patients who feel it will help them get around and are lured by the commercial that assures insurance coverage.

I figured I would wait until the patient came to the office to ask her about it.

That’s when things got interesting. She said someone had been calling her repeatedly asking if she has joint pain. She refused to answer a few times, but the calls kept coming, often at odd hours. The caller finally mentioned that if she answered a few questions, then that was all they needed. Before she knew it, the phone was transferred to someone else, and she was on the line with the representatives from the company that faxed me.

Technically, the fax was right that she had contacted the company, but through an intermediary who had persistently called her. And she had answered a few questions. She had been told she needed knee replacements but since she didn’t have pain, she didn’t think much about it. Sure, she had shoulder pain, that was chronic, and also back pain. If there was a brace that could take her pain away, of course she would want to live pain-free.

That explained the fax.

The form was already filled out with the types of braces she supposedly wanted, and suggested diagnoses for her insurance coverage, along with a request for clinic notes documenting the medical necessity of the braces that no one had requested.

This 10-minute phone call would have generated $3,966.92 in revenue for the use of braces that my patient openly admitted she didn’t need and had no intention of using.

I asked her if she had intended to wear all these braces, trying to picture her with a back brace, a shoulder brace and two knee braces. How would she even put these on herself? Would she be able to move with all of these devices? If she wasn’t having pain, why would she be wearing all of this?

As for how much all this would have cost, that took a bit of digging. The Centers for Medicare and Medicaid Services posts a list of coverage amounts for different codes on its website.

The back brace: $1,255.76.

The knee braces: $849.98 each

The shoulder brace: $1,011.20

This 10-minute phone call would have generated $3,966.92 in revenue for the use of braces that my patient openly admitted she didn’t need and had no intention of using.

The amount of information that the company gathered was alarming. Her address, birthdate, Medicare number, my name, National Provider Identifier number, office fax, address.

The idea seems foolproof. Fax paperwork to busy doctor’s offices. I’m certain that it’s often signed without a further glance. Once the braces are sent, Medicare is billed, and there is no way to return the products. If the proper authorization is not obtained, then the patient might be responsible to pay the full amount.

We all pay for this, because Medicare is funded by taxpayer dollars. That’s why it’s imperative to be wary of these types of scams. Sharing this information with your loved ones can help.

There are certainly people who need back, shoulder and/or knee braces. But responding to a telephone solicitation is not the best way to obtain medical equipment.

If my patient had actually needed a brace, the next step would have been to have her see an orthopedic specialist who would know exactly which type of brace she needed before finding a company that could fulfill her needs.

She decided she was fine without braces. And the next time someone calls soliciting her information, she’s going to hang up, and try to find a way to get off of the telemarketer’s list.

I am suggesting to all of my patients that they do the same.

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]]>Health Beat: Pharmaceutical Companies Are Ripping Off Americanshttps://www.civilbeat.org/2018/08/health-beat-pharmaceutical-companies-are-ripping-off-americans/
Wed, 15 Aug 2018 10:01:54 +0000https://www.civilbeat.org/?p=1293992When was the last time you went to pick up a prescription? Was it fairly cheap? These days copays have gone up, but generally generic medications cost patients $3 to $10 or so. Seems like a bargain. But what about the real cost of the medication? Chances are it’s a lot higher in this country […]

]]>When was the last time you went to pick up a prescription? Was it fairly cheap? These days copays have gone up, but generally generic medications cost patients $3 to $10 or so. Seems like a bargain.

But what about the real cost of the medication? Chances are it’s a lot higher in this country than others, and while consumers may be lulled by low copays, they still bear the cost in the end through higher insurance premiums.

There’s got to be a better way.

Rebates, patient copay cards and patient assistance programs are all designed to mask the true cost of medicine in America.

Flikr.com

Prescription coverage is included with most medical insurance plans. This could be run directly by the insurance company, or by a pharmacy benefit manager as an intermediary. For traditional Medicare, it’s the optional Part D plan. Medicare Advantage plans have their own drug coverage programs, and their own rules as well.

Many formularies have a listing of preferred drugs, with the generic medications usually at the lowest cost considered Tier 1. Brand name drugs are either preferred, leading to Tier 2 status, or non-preferred, leading to Tier 3 status. In some cases, coverage is limited to the first tier, or costs are managed by charging more for the higher tiers. Some plans have up to six tiers, with all different coverage requirements.

Copay amounts may be the only visible change for patients when they go to pick up their medication from the pharmacy. However, for the insurance plan, the cost for medications for a single patient can be in the thousands of dollars per year, and in some cases, per month.

For some branded medication, the copay for patients might be the same, but the cost to insurance varies greatly, with pharmaceutical companies offering a savings on the charge in the form of a rebate.

Pharmaceutical companies have no oversight regarding how much they charge for medication. Their only limiting factor is market competition, and if their product is the only one in that class, then the sky is the limit.

These rebates are in the crosshairs these days. Health and Human Services Secretary Alex M. Azar II has singled out rebates as a contributing factor in the high cost of prescription drugs. With rebates, the insurer or pharmacy benefit manager get a certain amount of money back from the pharmaceutical companies for the prescriptions that are filled with their medication.

The theory is that the elimination of rebates will lead to lower overall drug prices, or at least a shared savings model between the insurance company and the patients. However, even with that, it’s doubtful costs will go down substantially.

Why are rebates needed at all?

Pharmaceutical companies have no oversight regarding how much they charge for medication. Their only limiting factor is market competition, and if their product is the only one in that class, there is no limit.

Consider the cost for Solvadi, the first medication to market to treat Hepatitis C. With its initial release, the cost was $1,000 per pill for a total cost of $84,000 for a course of treatment. When this drug was combined with another one to make Harvoni, the cost went up to $94,500 for the 12-week treatment.

Pressed to explain the exorbitant prices, the pharmaceutical company Gilead and others have contended that the overall benefit of curing Hepatitis C is worth the cost, i.e., reducing the need for more expensive therapy for those who might otherwise need a liver transplant from cirrhosis, and reducing future transmission and subsequent cases of Hepatitis C.

Once competition arises, the cost of the medications decreases. Rebates, like those targeted by Azar, are offered by the more expensive brands, and the availability of the medication increases to cover more patients with Hepatitis C at various stages of liver damage.

Even with this automatic kickback from the pharmaceutical companies, the cost to insurance plans for the full treatment of one patient for Hepatitis C remains much more than the annual premium that one patient would pay for their coverage plan.

What if the cost was cheaper in the first place?

The makers of the Hepatitis C treatments know that other countries can’t afford to pay the prices charged in the US. In an effort to avoid knock-off medicine prior to their loss of the patent, the companies offer the same exact pill for pennies. Total cost for Hepatitis C treatment in other countries such as Egypt is $1,200 for a full course, and in India $900.

Canada recently negotiated a more favorable price for the medication and is expanding the offering of Hepatitis C treatment in several of its provinces.

So what’s the problem with all this?

In the U.S., the costs are driven by the market, and that results in ever-increasing premiums to cover the charges for expensive treatments. Without any power to negotiate lower overall prices, the only one left holding the bill is the consumer, in this case, the patient.

Even if their copay is a small amount each month, the cost to their insurance can be so great in the aggregate that the cost for the coverage goes up exponentially over time. Medication is not getting cheaper. With the newest immune therapy for cancer running in the hundreds of thousands of dollars, it’s only a matter of time before the system crashes and no one can afford their treatments.

Rebates, patient copay cards and patient assistance programs are all designed to mask the true cost of medicine in America.

Someday soon, there has to be some type of control established for the costs of the prescriptions we need the most, and not in the form of a rebate, but in true lowering of drug prices.

Thoughts on this or any other story? Write a Letter to the Editor. Send to news@civilbeat.org and put Letter in the subject line. 200 words max. You need to use your name and city and include a contact phone for verification purposes. And you can still comment on stories on our Facebook page.

]]>Health Beat: Yes, Patients Can Be Trusted With A First Look At Test Resultshttps://www.civilbeat.org/2018/07/health-beat-yes-patients-can-be-trusted-with-a-first-look-at-test-results/
Tue, 24 Jul 2018 10:01:13 +0000https://www.civilbeat.org/?p=1291396Electronic medical records help doctors keep track of patient conditions, prescriptions and consultations with other physicians. They also provide easy patient access to test results, x-rays, EKG’s and scans — usually after a doctor’s review. Today’s speed of technology raises compelling questions: Should patients have access to results as soon as they are posted, without […]

]]>Electronic medical records help doctors keep track of patient conditions, prescriptions and consultations with other physicians. They also provide easy patient access to test results, x-rays, EKG’s and scans — usually after a doctor’s review.

Today’s speed of technology raises compelling questions:

Should patients have access to results as soon as they are posted, without waiting for their doctor to release them? Would they even want to know all of their results if they didn’t know what it meant?

Medical test results could quickly be at your fingertips. But do you want your doctor to review them first?

Cory Lum/Civil Beat

A few years back, lab studies from my office were posted automatically. Initially, I thought that it would lead to an endless stream of emails of concern about results that looked abnormal, but really weren’t. However, most people seemed to realize they had upcoming appointments or figured out that if there was something really worrisome, I would contact them immediately.

Standard explanations about the meaning of tests became available, so that no one would be overly stressed about something like a low MCV (mean corpuscular volume), a test indicating the size of a red blood cell that often falls out of the standard range and is not a sign of danger. I still receive the occasional email of alarm, but it’s not a major burden.

The next step in the evolution of full transparency for medical records is the release of radiology reports, including x-rays, CT scans and MRI’s. Some organizations already release these to patients immediately, but this is not yet a common practice where I work.

In theory, any patient can show up at the medical records department and ask for a copy of their records anytime, but this would be an actual notification to patients that their test results were in and immediately available for perusal through their online portals.

When it was proposed as a future plan for increasing access to records, there were a lot of concerns among my colleagues, and myself as well.

What if a patient doesn’t understand the report and pages the doctor after hours to ask nonurgent questions?

What if patients find out sensitive results, like biopsies, on a weekend and then have to wait until Monday to ask their doctor for an explanation?

I am fortunate enough to have a plethora of patients to ask about issues like this. What I heard surprised me.

One gentleman in his mid-60s suggested that he would be in full support of getting all results in real time.

“I’m an optimistic person in general,” he said, “and I would expect to get good news. I’d rather have that then to wait several days or for an entire weekend wondering about it.”

A woman wanted access to test results, but only after I had reviewed them.

“If there was a way to know you saw it, then that’s fine with me, because you would let me know if it was serious, and I don’t want to find out I have a cancer and be all alone,” she said.

Still another patient explained that they would call a friend or do their own research on the internet if they had any questions, and that they would rather have the information on their own then wait around for me to let them know it’s okay.

“After all, you might be busy for a day or two, and I can handle what I read, and ask someone I know if it’s really scary and I need to know what to do asap,” this patient said. “Besides, I’m more likely to schedule a follow-up appointment if I know I have questions. I wouldn’t want to waste time coming in if everything was fine.”

A tech-savvy 80-year-old patient told me “Doc, if I don’t want to know, I won’t log on. But if I do, then I expect to have the results there for me to see when I want.”

My fears of patients being reluctant to have this level of transparency were apparently unfounded.

Time will tell if this whole plan backfires with me getting endless emails about the minutia of medical reports. But if patients truly want to get their results as soon as I do, I feel it’s their right.

It would be nice if reports were easier to read for nonmedical people. It would also be helpful if there were trustworthy websites where people could look up conditions and not get scary death tales of a rare situation that is unlike their own. But that day may not come anytime soon.

Thoughts on this or any other story? Write a Letter to the Editor. Send to news@civilbeat.org and put Letter in the subject line. 200 words max. You need to use your name and city and include a contact phone for verification purposes. And you can still comment on stories on our Facebook page.

]]>Health Beat: Marijuana Could Be Opioid Alternative — But Feds Just Say Nohttps://www.civilbeat.org/2018/07/health-beat-marijuana-could-be-opioid-alternative-but-feds-just-say-no/
Mon, 09 Jul 2018 10:01:45 +0000https://www.civilbeat.org/?p=1288645“We’re going to have to be very careful with these pain pills,” I said to one of my patients who was suffering from intermittent headaches. “There are some new laws in Hawaii that require that we review a few things if you’re going to be on any type of opioid pain medication for more than three […]

]]>“We’re going to have to be very careful with these pain pills,” I said to one of my patients who was suffering from intermittent headaches. “There are some new laws in Hawaii that require that we review a few things if you’re going to be on any type of opioid pain medication for more than three months.”

“Well, I don’t know how long this pain is going to last,” she replied.

“And right now, I don’t either,” I said. “But if we get to that three month time frame, we’re going to have to look at a couple more papers together and make sure we have a plan.”

“Can I qualify for medical marijuana if my headaches become chronic, instead of Tylenol with codeine? Would my insurance pay for that instead?” she asked.

Thus we hit an interesting predicament.

Medical marijuana might be a good alternative to painkillers, but federal restrictions are holding back research — and insurance coverage.

Anthony Quintano/Civil Beat

“No,” I told her. “Insurance won’t cover for medical marijuana, but might for other alternative treatments like acupuncture, massage, or other medications.”

In an effort to reduce the use of opiate-based treatments, physicians and patients alike have been forced to look for other options to meet the needs of those who suffer with chronic pain. Recent changes in the law have restricted the quantity of medication that can be given at any one time, and people are looking for other substitutes for pain pills.

What about medical marijuana?

Not enough is known about the use of this for chronic pain, but some of the same conditions that qualify patients to use medical marijuana include those for which they might now be taking painkillers like hydrocodone or oxycodone. Chronic headaches, migraines, fibromyalgia and chronic muscle spasms are on the list.

Could marijuana help to ease the opioid epidemic? Should insurance be required to cover it?

Medicare has taken a firm stance against this. With the current designation of marijuana by the U.S. Drug Enforcement Agency as a Schedule 1 narcotic, research is prohibited that might otherwise determine if there are any viable uses for marijuana to treat chronic pain. But all 30 states that have legalized medical marijuana have listed pain or some medical condition that causes pain as a qualifying condition.

Without the research to support its use, government and commercial insurance plans are not going to budge on their current coverage policies. This leaves patients to pay the difference — those who can afford it.

The research thus far has provided conflicting evidence on the efficacy of medical marijuana in reducing opioid use. The Lancet just published a prospective four-year analysis of patients who self-reported marijuana use in Australia, and found no clear association with the use of this substance medicinally on the overall amount of opioids that were taken, or any reduction in pain.

But earlier studies done in the U.S. have noted significantly lower overdose mortality rates from opioid use in states that have legalized the use of medical marijuana. These studies did not have a definitive explanation on why the overdose rates declined, but rather suggested more research needs to be done to substantiate the findings.

Which brings us back to the coverage of medicinal use of marijuana by commercial insurance companies. Annual expenditures for opioids are generally low, given the generic status of most of the medications in short-acting forms. Insurance does cover for these, along with some of the currently accepted non-opioid alternatives, including nerve medications like nortriptyline, gabapentin, pregabalin and NSAIDs. These are paid for with a drug plan, and may have a copay involved.

Alternatives to medication are also increasingly covered by local commercial insurance plans. Physical therapy, massage therapy, chiropractic care and acupuncture are often covered benefits or additional riders that can be purchased to supplement the primary health insurance plan.

So, with the added restrictions on the use of opiates, should patients be given the option of using their drug benefits on medical marijuana?

Opponents feel that until the research is done, there may not be a role for the use of marijuana to treat chronic pain, and without this peer-reviewed analysis to prove efficacy, there is no need to cover what could be considered “experimental treatment.”

Workers comp plans do not cover this, as proven in the recent case with the Hawaii Employers’ Mutual Insurance Company rescinding reimbursement for medical cannabis, stating it followed the federal Medicare fee schedule, which does not pay for medical marijuana. The case could go all the way to the Hawaii Supreme Court, in an attempt to legislate an answer to what is still not adequately determined in the medical literature.

That leaves patients to pay cash if they do qualify to purchase medical marijuana at the local dispensaries, and it is not cheap. The costs can run into hundreds of dollars a month to treat an illness that might be significantly less expensive if prescription opioids are used instead.

All of this leads to the absolute requirement that marijuana be removed from Schedule 1 status so that research can determine if it’s a viable alternative to the pain medications on the market.

Without the research to support its use, government and commercial insurance plans are not going to budge on their current coverage policies. This leaves patients to pay the difference — those who can afford it.

Thoughts on this or any other story? Write a Letter to the Editor. Send to news@civilbeat.org and put Letter in the subject line. 200 words max. You need to use your name and city and include a contact phone for verification purposes. And you can still comment on stories on our Facebook page.